assessment of menstrual hygiene management and its ...3 continuing regular activities like going to...

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Assessment of menstrual hygiene management and its determinants 4

among adolescent girls: A cross-sectional study in school adolescent 5

girls in Addis Ababa, Ethiopia. 6

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Ephrem Biruk1¶

, Worku Tefera2¶

, Nardos Tadesse3¶

, Ashagre Sisay4¶

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1Strengthen Ethiopian Urban Health Program, Quality improvement specialist, Addis Ababa, 13 Ethiopia/ SEUHP, Southern Program, Implemented by JSI, Addis Ababa, Ethiopia 14 2Department of Public Health, Addis Ababa University, Addis Ababa, Ethiopia 15

3Control of communicable disease prevention SURGE department, HTS coordinator 16 Implemented by Addis Ababa health bureau, Addis Ababa, Ethiopia 17

4Department of urban health extension program, Arada sub city health office, Addis Ababa 18

health bureau Addis Ababa, Ethiopia. 19

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* Corresponding author 22 E-mail:[email protected] (EB) 23

*Ephrem Biruk 24

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¶These authors contributed equally to this work. 27

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.CC-BY 4.0 International licenseacertified by peer review) is the author/funder, who has granted bioRxiv a license to display the preprint in perpetuity. It is made available under

The copyright holder for this preprint (which was notthis version posted October 23, 2018. ; https://doi.org/10.1101/450007doi: bioRxiv preprint

https://doi.org/10.1101/450007http://creativecommons.org/licenses/by/4.0/

Abstract 1

Introduction: Managing menstruation is essentially dealing with menstrual flow and also in 2

continuing regular activities like going to school, working etc. However, menstruation can place 3

significant obstacles in girls’ access to health, education and future prospects if they are not 4

equipped for effective menstrual hygiene management. 5

Objective: To assess the menstrual hygiene management and its determinant among school girls 6

in Addis Ababa, Ethiopia. 7

Methods: Cross-sectional study design with quantitative method was carried out among 770 8

systematically selected adolescent school girls of Addis Ababa from April 1 to May 5, 2017. A 9

self-administered pre-test close ended Amharic questionnaire at school setting was used for data 10

collection. The coding was done using the original English version and entered to EPI-7 11

software. The quantitative file exported to statistical package for social science (SPSS) version 12

25.0 software for analysis. Total mean score was used to categorize individuals as good and poor 13

while AOR; 95% CI with p < 0.05 was used to determine factors of menstrual hygiene 14

management practice. 15

Result: This study had 98% response rate. 530 (70.1%) and 388(51.3%) respondents had good 16

knowledge and practice of menstrual hygiene respectively. The findings also showed a 17

significant positive association between good knowledge of menstruation and girls from 18

mother’s whose education were secondary (AOR = 10.012, 95 % CI = 3.628-27.629). Wealth 19

index quantile five (AOR = 9.038, 95 % CI = 3.728-21.909) revealed significant positive 20

association with good practice of menstrual hygiene. 21

Conclusion and recommendation 22

Majority of participants had good knowledge and practice of menstrual hygiene and majority of 23

them were from private school. Although knowledge was better than practice, girls should be 24

educated about the process, use of proper pads or absorbents and its proper disposal. 25

Key Words: practices of menstrual hygiene, Menstrual knowledge, adolescent girl, Sanitary 26

napkins, Menarche, school health. 27

Introduction 28

Background 29 Menarche is an important milestone in a girl’s transition to womanhood (1). Around the world 30

women have developed their own personal strategies to cope with menstruation, which vary from 31

country to country and depend on economic status, the individual’s personal preferences, local 32

traditions and cultural beliefs and education status. The onset of menstruation presents multiple 33




challenges for school girls. Many girls lack the knowledge, support and resources to manage 1

menstruation in school (2). 2

Managing menstruation is essentially dealing with menstrual flow and also in continuing regular 3

activities like going to school, working etc (3). However, menstruation can place significant 4

obstacles in the way of girls’ access to health, education and future prospects if they are not 5

equipped for effective menstrual hygiene management (MHM). Good MHM requires access to 6

necessary resources (menstrual materials to absorb or collect menstrual blood, soap and water), 7

facilities (private place to wash, change and dry re-usable menstrual materials, in addition to an 8

adequate disposal system for menstrual materials), and education about MHM (1). 9

Schools, particularly those in developing countries, often completely lack drinking-water and 10

sanitation and hand washing facilities; even, where such facilities exist they are often inadequate 11

in both quality and quantity. Girls are likely to be affected in different ways from inadequate 12

water, sanitation and hygiene conditions in schools, because the lack of such facilities they 13

cannot attend school during menstruation (4). Girls are particularly vulnerable to dropping out of 14

school, partly because when toilet and washing facilities are not private, not safe or simply not 15

available in schools. Girls who reached puberty and female school staff need gender-related 16

privacy; otherwise they may not use the facilities. This may result in absenteeism rates that can 17

reach 10–20 per cent of school time (5). 18

Menstrual hygiene and management has not received adequate attention in the health and water, 19

sanitation and hygiene (WASH) sectors in developing countries including Ethiopia and its 20

relationship with and impact on achieving agenda of the sustainable development goal that 21

access to adequate and equitable sanitation and hygiene for all and end open defecation, paying 22

special attention to the needs of women and girls and those in Vulnerable situations (6). 23

Public investment in institutional sanitation, especially in schools and health facilities in urban 24

areas is limited. The available sanitation facilities in most secondary schools, are poor in 25

construction design; not convenient for sick, disabled, elderly and MHM. This in turn, results in 26

significant unwanted impacts on health, economic activity and education (7). 27

According to the WHO/UNICEF Joint Monitoring Programme (JMP, 2014), the estimated 28

coverage of urban sanitation indicated as improved, shared and other unimproved facilities have 29

reached 27%, 40% and 26% respectively in 2015 compared to 20%, 30% and 12% respectively 30

in 1990 (7). As a matter of fact, the existing sanitation condition for many of the school in 31

Ethiopia is horrendous. Most school latrines are filthy and unclean, and the poor condition is 32

contributing to high level disease prevalence, creates poor learning environments and especially 33

impacting on girls’ education (8). 34

However, much attention is not given to this problem and studies on menstruation and its 35

hygienic management as well as its influence on girls’ education are limited in Ethiopia. This 36




study therefore, will be conducted with the aim of assessing menstrual hygiene management 1

among primary and secondary school girls at both private and public schools. 2

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Objectives 1

General objective 2 To assess the menstrual hygiene management and its determinant among private and public adolescent 3

school girls in Addis Ababa, Ethiopia. 4

Specific objective 5 To measure level of knowledge about menstrual hygiene management among adolescent school girls. 6

To measure level of menstrual hygiene management practice among adolescent school girls. 7

To determine factors affecting menstrual hygiene management knowledge and practice among adolescent 8

school girls. 9

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Methods 1

Study area 2 The study was conducted among primary and secondary school girls in Addis Ababa a capital of Ethiopia, 3

from April 1 to May 15, 2017. 4

Addis Ababa was established in 1886 by Emperor Taitu and Minilik II and is the capital city of Federal 5

Democratic Republic of Ethiopia. Addis Ababa is located in an area of 540.1 square kilometers and 6

located at 9°2'0" North and 38°42'0" East at range of 2200 – 2800 meters above sea level. Despite its 7

proximity to the equator, its lofty altitude - the third-highest capital in the world - means that it enjoys a 8

mild climate with an average temperature of 16°C (61°F). The hottest, driest months are usually April and 9

May. The city has administrative structures: one city council, 10 sub-cities and 116 woredas. The total 10

population of the city projected for the year 2016, by Population Census Commission, was 3.3 million 11

with male to female ratio of 0.92 (29). 12

The city has a total of 203 government and 612 private schools. Of the total number of 107,106 students 13

enrolled from grade 7th to 10

th education in the year 2016/17 were females (26). 14

Study design 15 School based cross-sectional study with a quantitative research methods was employed. The survey was 16

conducted among female adolescent students. The interviews were explored female students’ views about 17

menstruation and its hygienic management and availability, accessibility and adequacy improved 18

sanitation and hygiene keeping facilities for menstrual hygiene management. 19

Population 20

Source population 21 The source population of the study was all grade 7th to 10th students in public and private schools of the 22

selected sub cities of Addis Ababa. 23

Study population 24 The study population was all grade 7

th to 10

th students from the selected public and private schools. 25

Study subjects 26 The study subjects were 770 randomly selected students and from whom data were collected. 27

Inclusion and Exclusion criteria 28

Inclusion criteria: 29 All students who were from grade 7

th to 10

th and has monarchy was included in the study. 30

Exclusion criteria: 31 All female students who had sight problems and with mental disorders were not be included in this study. 32




Sampling 1

Sample size determination for quantitative study 2 To determine the number of adolescent school girls to be included in the study, a two-population 3

proportion formula were used. Since the specific objectives are three, were calculated a sample size for 4

each in order to take a large sample size. 5

Specific objective 1 6

The sample size of this study was determined using a single proportion formula n = (𝑧𝛼2)2

𝑃(1−𝑝)

𝑑2 where 7

𝑧𝛼2= 95% level of confidence (1.96), p= proportion of menstrual hygiene management practice among 8

adolescent school girls in previous study (prevalence of use of sanitary napkins 35.38%) (13) and d= 9

margin of error (5%), based on these assumption that sample size found to be 350 and to maximize the 10

response rate of the study sample size population correction were made by multiplying design effect 2 and 11

10% non-response rate. Based on the above assumptions the total sample size for objective one “n” was 12

770 school girls. 13

Specific objective two and three 14

For the second objectives: factors affecting menstrual hygiene management knowledge and practice 15

among adolescent school girls, sample size was calculated using two population proportion formula (13). 16

n=Zα/2√ (1+1/r) p(1-p)-Zβ√P1(1-P1) +[P2(1-P2)/r}2 17

(P1-P2)2

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Where 19

Zα/2: 95% confidence level

Zβ: power

P1: the probability of event in the unexposed

P2: the probability of event in the exposed

r: ratio of exposed to unexposed

OR: 1.5

It was calculated using statcalc sample size and power calculation for descriptive study of Epi info

version 7




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So, decision was made based on the comparison between the first specific objective (770) and second 1

objectives (434). Finally, due to the issue of representativeness a sample size of 770 were used in the 2

study. By using sample proportional to size, determine sample size to each school. Twenty primary and 3

secondary schools at private and public were selected systematically from the list of schools from the 4

selected sub-cities of Addis Ababa. A total of 770 school girls were randomly selected from students 5

networking list of selected schools based on the proportion to the size of grade seven to ten of each 6

school. 7

Sampling procedures 8 The target participants for this study was adolescent school girls from grade 7

th to 10

th in

very selected 9

schools of five sub cities of Addis Ababa. A multi-stage probability sample procedure was used to select 10

participant schools. twenty Primary and secondary schools were selected randomly from the list of 11

schools which have grade seven to ten in the Regional Education bureau. A total of 770 School girls were 12

randomly selected from students networking list of selected schools based on the proportion to the size of 13

grade seven to ten of each school. The reason for the choice of school girls in grade seven to ten was 14

because they start their menarche. 15

Data collection tool and procedure 16 A self-administered pre-test close ended Amharic questionnaire at school setting were used. The 17

questionnaire was contained variables related to socio-demographic characteristics, knowledge about 18

menstruation and menstrual hygiene management, practice about menstrual hygiene. Study subjects were 19

invited to take part voluntarily by explaining the purpose of the study and data were collected after 20

obtaining verbal consent. Data was collected by ten female health professional data collectors with health 21

background one supervisor. 22

Students were instructed on how to fill the questionnaire. Data quality was assured through careful design 23

of the questionnaire. Data collectors and supervisor were received a one-day training on the purpose and 24

procedure of data collection related to this research. During the training, special emphasis was given to 25

establishing trust before asking questions. The training session were also pay attention to careful 26

consideration for sensitive questions, observations where needed, and avoidance of participation bias. 27

Data were checked for completeness and consistency after each day of data collection checking filled 28

questionnaires by supervisors. The overall data collection process was coordinated by the principal 29

investigator. 30

Variables 31

Dependent variables 32 Practice on menstrual hygiene management. 33

Independent variables: - 34 Socio-demographic variables 35

Age 36

Grade 37




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School type 38

Religion 39

Parent’s education 40

Parent’s occupation. 41

Menstrual hygiene related Variables including: 42

School learning on menstrual hygiene. 43

Discussion with parents on menstrual hygiene. 44

Information before menarche on menstrual hygiene. 45

Data analysis 46 All responses to the survey questionnaires were coded on pre-arranged coding sheet by the principal 47

investigator to minimize errors. The coding will be using the original English version and were entered to 48

EPI-7 software. The data file will export to statistical package for social studies (SPSS) version 25.0 49

software for analysis. Descriptive analysis including frequency, proportions, and measures of mean were 50

done. Cross tabulations were made to calculate Crude and adjusted odds ratio. All variables with p

21

menstrual hygiene was given to those respondents who scored 0–7 points. Each correct response earned 73

one point, whereas any wrong or don’t know response attracted no mark (12). 74

Hygienic menstrual management practice in school – adolescent school girls using a clean menstrual 75

management material to absorb or collect blood that can be changed in privacy as often as necessary for 76

the duration of the menstruation period, using soap and water for washing the body as required, and 77

having access to facilities to disposed of used menstrual management materials (4). 78

Secondary school – a high school or a senior high school which provides secondary education, between 79

the ages of 14-19, after primary school and before higher education(26). 80

Primary school - a primary school or elementary school which provides primary education, between the 81

ages of 6-14, after kinder-garden school and before secondary education(16). 82

Access to water supply– Sufficient water-collection points and water-use facilities are available in the 83

school to allow convenient access to, and use of, water for drinking, personal hygiene, cleaning and 84

laundry (4). 85

Address the gender-related needs: The number, location, orientation of school WASH facilities should 86

take into consideration of the gender factor (gender mainstreaming) (8). 87

Adequacy of safe water- is the availability of 5 liters per person per day for all schoolchildren and staff 88

at day schools(4). 89

Appropriate designs for different age groups: The detailed design of the facilities provided must also 90

be young child friendly. Steps must be easy to climb. Door handles must be easy to reach. The toilet 91

interior cannot be too dark. Squatting plates must be designed to accommodate a child’s feet rather than 92

those of an adult (8). 93

Improved sanitation - are those more likely to ensure privacy and hygienic use /easily cleanable which is 94

not full, do not have fecal matter in the squat (24) 95

Physically separate facilities: Physically separated facilities must be provided for girls, spaced 96

sufficiently apart to ensure that girls do not feel embarrassed but secure when approaching and using the 97

facilities. Separate hand-washing areas should also be provided, affording privacy for girls who may need 98

to wash and dry menstrual cloths (8). 99

Use appropriate orientation of facilities: Specifically, the direction that the toilet entrance faces, must 100

also take into account the perceived security and safety of girls. The orientation of the squatting plate 101

should also take into account cultural and religious norms (8). 102

Ethical consideration 103

Ethical clearance was secured from School of Public Health, College of Health Sciences, Addis Ababa 104

University Research Ethics Committee. Approval letter was obtained from Addis Ababa City 105

Administration Education Bureau in the respective schools included in this study. School directors and 106

directresses were briefed on the objectives of the study and permission to conduct the study was obtained 107

from participating schools. The questions from the questionnaire prove not to affect the morale and 108




22

personality of study subjects. Informed verbal consent was obtained from each study subject after 109

explanation of the objective of the study. Confidentiality was ensured from all data collectors via using 110

code numbers than names and keeping questionnaires locked. Data collectors also give health education 111

and advice to the subjects during the data collection process. 112

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Result 137

Socio-demographic characteristics of study population 138

A total of 756 primary and secondary school girls were participated from twenty primary and secondary 139

schools, with response rate of 98%. Among these participants 38.1 % (288) were from private and the rest 140

61.9 % were from government schools. Among the total respondent 156 (20.6%), 160 (21.2%), 220 141

(29.1%) and, 220 (29.1%) were grade seven, eight, nine and ten respectively. The mean age of the study 142

participants was 14.89 with SD + 1.285 years, while their age range between 12-20 years. The mean age 143

of menarche of the respondents was 12.84 with SD +0.745 years. 144

The study also indicated that 267 (35.3%) and 226 (29.9 %) of the respondents’ father completed 145

secondary and higher level of education respectively. Regarding respondent’s mother occupation, 255 146

(33.7%) of them were house wife while 156 (20.6%) government employed. The majority 70.2% (531) of 147

the respondents didn’t earn pocket money form their families. The quintile division showed that, wealth 148

was almost equally distributed across the five quintiles. 20.5% of respondents were in the lowest quintile 149

whereas 18.7% in the highest quintile (See table 2) 150

Table 1 Socio-demographic characteristics of primary and secondary school girls, April 1 to May 151

15, 2017 Addis Ababa, Ethiopia. (n =756) 152

Characteristics of respondents Frequency Percentage

Religion Orthodox 528 69.8

Muslim 154 20.4

Protestant 59 7.8

Catholic 15 2.0

Wealth using the wealth index Quintile One 155 20.5

Quintile two 148 19.6

Quintile three 151 20.0

Quintile four 161 21.3

Quintile five 141 18.7

Mothers educational status Illiterate 206 27.2

Read & write 84 11.1

Primary 175 23.1

Secondary 163 21.6




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College and above 128 16.9

Live with Both parents 651 86.1

only mother 59 7.8

Relatives 24 3.2

Only father 22 2.9

Fathers occupation Merchant 204 27.0

Employed in private organization 197 26.1

Governmental employee 180 23.8

Driver 94 12.4

Daily laborer 81 10.7

153

Adolescent school girls’ knowledge about menstruation and its hygienic management 154

This study also found that 83 percent of respondents knew about menstruation before it occurred and their 155

chief source of information was mothers (68.3%) followed by friends (41.08%), elder sister (32.48%) and 156

school (28.18%). Out of the total respondents, 392 (50.9%) didn’t learn about menstrual hygiene in the 157

school. Two hundred three (26.9%) of the respondents didn’t discuss about menstrual hygiene with their 158

parents and friends. 159

Out of the total, 599 (79.2%) of girls knew that menstruation was a physiological process, whereas 42 160

(5.6 %) of the them believed that it was a curse from God. Majority of girls (69.3%) correctly responded 161

hormone as the cause of menstruation. More than half, 64.6% of the respondents knew that uterus is the 162

source of menstrual blood. (See table 3) 163

Table 2 School girls’ Information and knowledge grading on menstruation and its management, 164

April 1 to May 15, 2017 Addis Ababa, Ethiopia. (n =756) 165

Variables Number Percentage

Normal menstruation cycle

Less than 25 days 84 11.1

25 to 28 days 515 68.1

28 to 35 days 104 13.8

More than 35 days 53 7.0




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Normal regular menstrual bleeding duration

< 2 days 52 6.9

2 to 7 days 676 89.4

>7 28 3.7

Knew that there is foul smelling during menstruation

No 142 18.8

Yes 614 81.2

Knew that menstrual blood is unhygienic

No 200 26.5

Yes 556 73.5

Knew Pain during menstruation means that’s one not sick

No 254 33.6

Yes 502 66.4

Knew menstruation is not harmful for a woman’s body if she runs

or dances during her period

No 229 30.3

Yes 527 69.7

Hear about menstruation before attaining menarche

No 116 15.3

Yes 640 84.7

Menstruation is not a lifelong process

No 130 17.2

Yes 626 82.8

Knew that a girl should take more nutritious diet during

menstruation

No 190 25.1

Yes 566 74.9




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Based on the Knowledge summary of the respondent, 70.1% (67.1-73.5) had good knowledge about 166

menstruation and its hygiene while 29.9 % of them had below the mean score of knowledge and 167

categorized as poor knowledge. 168

Menstrual Hygiene Practice 169

Out of the total respondents, 52.5 % (48.7-56.1) of the respondents had good practice on menstrual 170

hygiene. Majority 457 (60.4%) of students used sanitary napkins and the rest 295 (39%) and 4 (0.5%) of 171

them used homemade cloth and underwear as menstrual soak-up during their last menstrual period 172

respectively. This study also enlisted the main reason for the non-use of sanitary napkins includes; 173

149(53.02%) high cost, 99(35.23%) difficulty in disposal, and 33(11.74%) lack of knowledge. Five 174

hundred thirty-one participants change their pads during menstruation at school. Half 384 (59.3 %) of 175

girls change their pads three and above times per day and 129(17.1%) changed their pads once in a day. 176

177

Table 3 Practice grading on MHM among private and government school girl’s, April 1 to May 178

15, 2017 Addis Ababa, Ethiopia. 179

Variables Number Percentage

Change pads at school

No 225 29.8

Yes 531 70.2

Frequency of changing absorbent material per day

Once 129 17.1

Twice 179 23.7

Three times 399 52.8

More than three times 49 6.5

Clean genitalia

No 212 28.0

Yes 544 72.0

Material used for genital cleaning

Soap and water 207 38.05

Water only 307 56.43




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Plain paper 30 5.51

Clean external genitalia

No 254 33.6

Yes 502 66.4

Materials for cleaning external genitalia



Plain paper 40 7.97

Hand washing

No 370 48.9

Yes 386 51.1

Materials for hand washing



Shower

No 238 31.5

Yes 518 68.5

Materials for showering


Water only 12 2.22

Drying of washed reusable cloths

In the shade, outside 68 9.0

In the shade, inside 201 26.6

In the sunlight, inside 201 26.6

In the sunlight, outside 131 17.3

Hidden under other clothes 60 7.9




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Hidden elsewhere 95 12.6

Six hundred forty (84.7 %) of the respondents disposed their used sanitary pads in the latrine, 68(9%) 180

wrap in paper and put in the bin, and the rest 48(6.3%) threw in the open field. Three hundred thirty-one 181

(43.9%) of the respondents dried their reusable sanitary pads in sunlight. 32.4% of the study participants 182

store their sanitary pads in separated plastic bag for the next use. (see table 4) 183

This study evidenced that menstrual hygiene practice related school absenteeism was prevalent amongst 184

respondents, 64.3% of whom miss school at least once in a month (mean 1.14, SD 1.132). Out of these 185

respondents, 348(46.03%) of the girls were absent from school during their last menstrual period up to 186

four days. The main reasons for school absenteeism during menstruation were; pain 294 (79.03%), 187

followed by lack of washing facility at school 292 (78.49%), feel uncomfortable or tired 207 (55.65%), no 188

private place to change sanitary pad 197 (48.12%), and didn’t have sanitary pad, 98 (26.34%). 189

Association between overall good knowledge of menstrual hygiene management and socio demographic 190

factors 191

The crude value in the bivariate analysis, some of socio-demographic characteristics of the respondents 192

were significantly associated with the outcome variable-knowledge of menstrual hygiene. The odds of 193

good knowledge about menstruation and menstrual hygiene were 7.01 times higher for those respondents 194

from private school compared to the government once (COR=7.01%, 95% CI: 4.936-9.952). Whereas the 195

odds of good knowledge about menstruation and menstrual hygiene were 31.493 times higher for 196

respondents’ mother education collage and above compared to the illiterate (COR=31.493%, 95% CI: 197

13.959-71.053). Unlike the crude value, the controlled model found that only the highest categories of 198

wealth were associated with the knowledge. Girls from the wealthiest family were [AOR = 3.199, 95 % 199

CI: 1.082-9.454] more likely to have good knowledge about menstruation and menstrual hygiene when 200

compared to those from non-wealthy. (see table 6) 201

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Table 4 Crosstabulations between socio-demographic variables and knowledge about menstrual 208

hygiene management among primary and secondary school girls, April 1 to May 15, 2017 Addis 209

Ababa, Ethiopia. (n =756) 210

Characteristics Knowledge Crude OR

Poor Good Total 95% (CI)




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Wealth index

Quintile One 109 46 155 1

Quintile two 58 96 148 3.68(2.28-5.93) *

Quintile three 35 116 151 7.85(4.71-13.098) *

Quintile four 8 153 161 45.318(20.568-99.85) *

Quintile five 16 125 141 18.52(9.92-34.556) *

School type

Private 75 213 288 1

Government 151 317 468 0.74(0.533-1.025)

Age at first menarche

13 69 69 138 2.94(2.01-4.29) *

Grade

Primary 166 150 316 1

Secondary 60 380 440 7.01(4.94-9.95) *

Live with

Both parents 139 512 651 1

Only mother 47 12 59 0.069 (0.036-0.134)

Only father 18 6 24 0.090 (0.035-0.232)

Relatives 22 0 22 0.000 (0.000-0.000

Mothers educational status

Illiterate 133 73 206 1

Read & write 27 57 84 3.846(2.24-6.598) *

Primary 36 139 175 7.04(4.42-11.195) *

Secondary 23 140 163 11.09(6.56-18.75) *

College and above 7 121 128 31.49(13.96-71.05) *




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Fathers educational status


Read & write 42 30 72 1.404 (0.735-2.683)

Primary 30 75 105 4.914(2.66-9.095) *

Secondary 82 185 267 4.434(2.64-7.438) *


Fathers occupation

Merchant 55 149 204 7.74(4.31-13.898) *

Private employee 36 161 197 12.778(6.91-23.62) *

Governmental employee 26 154 180 16.92(8.85-32.35) *

Driver 49 45 94 2.62(1.38-4.98) *

Daily laborer 60 21 81 1

Mothers occupation

Housewife 113 142 255 1.374(0.802-2.357)

Merchant 29 86 115 3.24(1.714-6.138) *




Earn pocket money

Yes 46 179 225 1.99(1.38-2.89) *

No 180 351 531 1

*P

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wealthiest family were [AOR = 3.199, 95 % CI: 1.082-9.454] more likely to have good knowledge about 219

menstruation and menstrual hygiene when compared to those from lowest quantile. (see table 6) 220

Table 5 Association between socio demographic factors and knowledge about MHM among 221

primary and secondary school girls, April 1 to May 15, 2017 Addis Ababa, Ethiopia. (n =756) 222

Characteristics Knowledge Crude OR Adjusted OR

Poor Good Total 95% (CI) 95% (CI)

Age of the respondents

=15 years 94 357 451 2.898(2.102-3.904) 0.819(0.344-1.950)

Wealth index

Quintile One 109 46 155 1 1

Quintile two 58 96 148 3.677 (2.282-5.925) 2.090 (0.826-5.289)

Quintile three 35 116 151 7.853(4.709-13.098) 2.079 (0.815-5.303)

Quintile four 8 153 161 45.318(20.568-99.85) 4.050(1.265-12.966) *

Quintile five 16 125 141 18.512 (9.917-34.556) 3.199(1.082-9.454) *

Grade

Primary 166 150 316 1 1

Secondary 60 380 440 7.01(4.936-9.952) 13.742(5.390-35.037) *

Mothers educational status

Illiterate 133 73 206 1 1

Read & write 27 57 84 3.846 (2.242-6.598) 0.705 (0.257-1.934)

Primary 36 139 175 7.035 (4.420-11.195) 5.718(2.548-12.831) *

Secondary 23 140 163 11.090 (6.558-18.7530) 10.012(3.628-27.629) *

College and above 7 121 128 31.493 (13.959-71.053) 6.101(1.779-20.919) *

Fathers educational status


Read & write 42 30 72 1.404 (0.735-2.683) 1.245 (0.376-4.125)




32

Primary 30 75 105 4.914 (2.655-9.095) 1.284 (0.444-3.709)

Secondary 82 185 267 4.434 (2.644-7.438) 0.796 (0.302-2.098)

College and above 15 211 226 27.648 (13.887-55.045) 2.197 (0.648-7.450)

Fathers occupation

Merchant 55 149 204 7.740(4.311-13.898) 0.880 (0.284-2.726)

Private employee 36 161 197 12.778 (6.912-23.621) 0.888 (0.274-2.874)

Governmental employee 26 154 180 16.923(8.854-32.346) 2.973(0.863-10.250)

Driver 49 45 94 2.624(1.382-4.981) 1.568 (0.510-4.821)

Daily laborer 60 21 81 1 1

Mothers occupation

Housewife 113 142 255 1.374(0.802-2.357) 2.301 (0.686-7.721)

Merchant 29 86 115 3.244(1.714-6.138) 1.135 (0.300-4.289)

Private employee 41 123 164 3.281(1.809-5.953) 0.391 (0.103-1.488)

Governmental employee 8 147 155 20.098(8.522-47.398) 10.555(2.047-54.411) *



13 69 69 138 2.936 (2.009-4.292) 2.093 (0.914-4.793)

Earn pocket money

Yes 46 179 225 1.99(1.378-2.890) 0.741(0.392-1.400)

No 180 351 531 1 1

*P=13) and pocket money were significantly associated with 95 % CI COR at P

33

The crude value also showed that the odds of overall practice of menstrual hygiene management among 230

secondary school girls were 2.364 (95% C.I: 1.759-3.177) times higher compared to primary school girls. 231

In this study, it was found that pocket money was associated with overall practice of menstrual hygiene 232

management. The odds of overall practice of menstrual hygiene management among girls 2.177 (95% 233

C.I: 1.575-3.009) times higher for respondent who had earned pocket money from their families. The 234

odds of overall practice of menstrual hygiene management among girls 2.330 (95% C.I: 1.720-3.156) 235

times higher among respondent who were from private school than government school girls. (see table 7) 236

Table 6 Crosstabulations between socio-demographic variables and MHM practice among 237

primary and secondary school girls, April 1 to May 15, 2017 Addis Ababa, Ethiopia. (n =756) 238

Characteristics Practice Crude OR

Poor Good Total 95% (CI)

School type

Government 259 209 468 1

Private 100 188 288 2.33(1.72-3.16) *


=15 years 179 272 451 2.19(1.63-2.94) *

Wealth index

Quintile One 133 22 152 1

Quintile two 91 57 148 3.79(2.16-6.63) *

Quintile three 74 77 151 6.29(3.620-10.931) *

Quintile four 32 129 161 24.37(13.45-44.16) *

Quintile five 29 112 164 23.35(12.71-42.91) *

Grade

Primary 189 127 316 1

Secondary 170 270 440 2.36(1.76-3.18) *

Religion

Orthodox 282 246 528 1

Muslim 40 114 154 0.582(0.204-1.657)




34

Protestant 31 28 59 1.900(0.636-5.674)

Catholic 6 9 15 0.602(0.19-1.906)

Live with

Both parents 269 382 651 1

Only mother 44 15 59 0.280(0.131-0.440)

Only father 24 0 24 0.998(0.000-0.000)

Relatives 22 0 22 0.998(0.000-0.000)

Mothers’ educational status


Read & write 42 42 84 2.68(1.58-4.54) *

Primary 100 75 175 2.01(1.31-3.08) *

Secondary 48 115 163 6.42(4.07-10.12) *


Fathers’ educational status


Read & write 49 23 72 1.365(0.683-2.730)

Primary 39 66 105 4.92(2.634-9.203) *

Secondary 135 132 267 2.84(1.657-4.884) *


Fathers’ occupation

Merchant 74 130 204 9.19(4.757-17.750) *



Driver 76 18 94 1.239(0.565-2.716)


Mothers’ occupation




35

Housewife 145 110 255 2.63(1.407-4.92) *

Merchant 41 74 115 6.26(3.140-12.47) *





13 91 47 138 2.53(1.718-3.72) *

Earn pocket money

Yes 77 148 225 2.18(1.575-3.01) *

No 282 249 531 1

*P

36

Private 100 188 288 2.330(1.720-3.156) 1.09(0.64-1.85)


=15 years 179 272 451 2.188(1.627-2.942) 2.832(1.62-4.97) *

Wealth index

Quintile One 133 22 152 1 1

Quintile two 91 57 148 3.787 (2.164-6.626) 2.968(1.32-6.67) *

Quintile three 74 77 151 6.291 (3.620-10.931) 3.80(1.730-8.35) *

Quintile four 32 129 161 24.371 (13.45-44.16) 14.776(6.23-35.04) *

Quintile five 29 112 164 23.348 (12.71-42.91) 9.038(3.728-21.91) *

Grade

Primary 189 127 316 1 1

Secondary 170 270 440 2.364(1.759-3.177) 3.115 (1.606-6.04) *

Mothers’ educational status


Read & write 42 42 84 2.679(1.582-4.535) 1.588(0.71-3.560)

Primary 100 75 175 2.009(1.308-3.084) 1.929(0.95-3.933)

Secondary 48 115 163 6.417(4.069-10.122) 7.761(3.58-16.81) *

College and above 19 109 128 15.367(8.639-27.352) 17.91(6.65-48.22) *

Fathers’ educational status


Read & write 49 23 72 1.365(0.683-2.730) 0.482(0.146-1.588)

Primary 39 66 105 4.923(2.634-9.203) 0.552(0.218-1.403)

Secondary 135 132 267 2.844(1.657-4.884) 0.570(0.110-1.663)

College and above 72 154 226 6.222(3.556-10.887) 0.574(0.099-1.761)

Fathers’ occupation

Merchant 74 130 204 9.189(4.757-17.750) 1.933(0.705-5.295)




37

Private employee 55 142 197 13.505(6.911-26.391) 3.65(1.22-10.991) *

Governmental employee 86 94 180 5.717(2.951-11.078) 1.178(0.413-3.363)

Driver 76 18 94 1.239(0.565-2.716) 0.481(0.166-1.391)


Mothers’ occupation

Housewife 145 110 255 2.630(1.407-4.916) 2.125 (0.759-5.952

Merchant 41 74 115 6.257(3.140-12.470) 1.570 (0.522-4.718

Private employee 63 101 164 5.558(2.887-10.699) 1.259 (0.448-3.539

Governmental employee 58 97 155 5.798(2.996-11.219) 0.813 (0.272-2.435



13 91 47 138 2.529(1.718-3.721) 2.57(1.41-4.69) *

Earn pocket money

Yes 77 148 225 2.177(1.575-3.009) 1.11(0.67-1.81)

No 282 249 531 1 1

*P

38

the school

Yes 316 55 4.59(3.24-6.51) 3.11(1.57-6.16) *

No 214 171 1 1

Discuss about menstrual hygiene

with their parents

Yes 481 72 20.99(13.99-31.51) 10.89(5.39-21.98) *

No 49 154 1 1

Heard about menstruation before

attaining menarche

Yes 500 140 10.24(6.49-16.15) 5.03(2.21-11.48) *

No 30 86 1 1

*P

39

attaining menarche

Yes 37 269 4.78(3.003-7.59) 0.779(0.366-1.656)

No 26 92 1 1

*P

40

Ethiopia and Jammu District India showed that, parental education was positively associated with girls’ 304

menstrual knowledge (12,30). The reason could that educated mothers may provide information about 305

menstruation and menstrual hygiene to their daughters. Girls from educated families may discuss openly 306

about menstruation. 307

Unlike a study done in Amhara region, Ethiopia 2016 [AOR = 0.94, 95 % CI: 0.46–1.92], this study 308

found that, the grade level of respondents was positively and significantly [AOR = 13.74, 95 % CI: 5.39-309

35.04] associated with knowledge about menstruation and menstrual hygiene management. Due to the 310

fact that high school girls might have high possibility for exposure to information regarding menstruation 311

and its hygienic management (11). in another study done in Odisha, India 2015, none of the mother’s 312

occupational category were significantly related with knowledge (25). But in this study only government 313

employed mothers were the one associated with knowledge on menstruation. 314

Regarding hygiene related practices during menstruation, this study found that 9.27% girls took daily bath 315

during menstruation and 29.48% clean their external genital with soap and water during menstruation. A 316

similar study done in Jammu and Kashmir, India indicated that 93.18% had daily bath and 66.67% clean 317

external genital with soap and water (30). The difference might be due to socio cultural, weather 318

condition and economic factors. 319

In this study, three hundred ninety-seven (52.5%) of the respondents had good practice of menstrual 320

hygiene. The finding of this study was lower than studies conducted in the Amhara region of Ethiopia and 321

Jammu and Kashmir, India which were 84.28 % and 59.09%, respectively (30,33). Comparatively, lower 322

level of practice of menstrual hygiene was recorded from similar study conducted on high school girls in 323

Western Ethiopia, it was indicated that only 39.9 % of the study participants practice good menstrual 324

hygiene (12). Thus, the reason for the observed difference could be due to low awareness and 325

communication of menstrual hygiene by high school Western Ethiopia girls which affects their menstrual 326

hygienic practice. 327

In this study, it was found that 17.3% of the study participants dried their reusable pads in the sun light 328

outside which is similar with the finding in Amhara, Ethiopia 15.5% of the participants dried in the sun 329

light. In contrast, a study done in central India indicated that 93% of adolescent girls dried reusable pads 330

in the sun light (32,33). This difference might be due to different in the socio-cultural factors. 457(60.4%) 331

of participants use disposable sanitary pads during menses. In a similar study done in Argoha village of 332

Haryana and central India Indicated that, 80.7 % and 98% girls use only napkin during menses 333

respectively (31,32). Comparatively, lower level of use of sanitary pads was recorded from similar study 334

conducted on high school girls in north east Ethiopia, it was indicated that 35.38% of the study 335

participants use disposable sanitary pads during menses. This may be due to differences in socio 336

economic differences. The main reason for not using pads in present study was non-affordability due to 337

high cost (53.02%) followed by non-availability and disposal problems which is similar to study in 338

Jammu district India(78.94%) (30). 339

The adjusted value of this study found that, both mother’s educational category was [AOR = 7.761, 95 % 340

CI: 3.583-16.809] positively associated with practice of menstrual hygiene which agrees with the study 341

done in western Ethiopia, in 2014 and Northeast Ethiopia [AOR = 2.03, 95 % CI: 1.38–2.97] [AOR = 342

4.26, 95 % CI: 1.61 - 11.28] respectively (11,12). Multivariable analysis showed that girls who learn and 343

discuss about menstrual hygiene in their school and with their parent were 2.472, and 13.651 times more 344




41

likely to had good practice about menstruation and menstrual hygiene than their counterparts. A similar 345

study done in northeast Nigeria that learn about menstrual hygiene in the school was positively associated 346

with girl’s menstrual practice (34). Possibly due to information provided about menstrual hygiene 347

management at schools. Students whose age above fifteen were 2.832 times more likely to have good 348

practice than age less than fifteen a similar study done in northeast Nigeria. A significant association was 349

also observed between girls whose first menarche were above thirteen (AOR= 2.572) and below with the 350

practice of MHM. Which was also significant in another study done in south India (24). 351

352




42

Conclusion 353

Seventy percent of the participants had good knowledge of menstruation and menstrual hygiene and it 354

was better among private school girls than the government. Half of the total respondents had good 355

practice of menstrual hygiene among respondents, and alike to that of knowledge, the large proportion of 356

them were from private school. 357

Good knowledge of menstruation showed a significantly positive association with the level of grade, 358

educational status of the mother, and mother’s occupational status. Except for the level of grade, all the 359

above variables plus current age of respondents’ and age at first menarche were positively associated with 360

practice of menstrual hygiene management. 361

All those factors considered in addition to socio demographic variables, which assume to be predictive of 362

the outcome variables including learn about menstrual hygiene in the school, discuss about menstrual 363

hygiene with their parents and friends and hear about menstruation before attaining menarche were 364

positively associated. 365

Recommendation 366

Federal level managers are recommended to: 367

Strengthen the enabling environment through advocacy and policy initiatives for improved WASH and 368

MHM education. 369

Promote an innovative, intercultural, multi-sectorial and gender approach in all programming, ensuring 370

that MHM aspects are included in planning processes and budget allocation processes by the water and 371

sanitation, health, and education ministries. 372

Regional Level: in addition to federal recommendations, regional level managers are advised to: 373

Give technical assistance and advocacy to prioritize budgets and investment in WASH facilities in 374

schools by health, and education bureau. 375

Strengthen teachers’ capacities and equips them with tools to provide in-depth and medically accurate 376

information to students in a safe learning environment by education bureau. 377

Strengthen school health packages provided by health extension professionals by health bureau. 378

School level managers suggested to: 379

Establish coordination between students, teachers and parents to improve MHM conditions at schools. 380

Complement menstrual hygiene management as part of the school health programs and should also give 381

special attention towards making schools a comfortable place for girl’s menstrual hygiene practice by 382

continuous provision of sanitary pad especially for the neediest ones. 383

Consult parents about the need to support their children with sanitary materials for menstrual hygiene in 384

addition to other basic hygienic products during parent-school teacher meeting. 385




43

Educate and counsel girls about the important and the need for good personal hygiene including hand 386

washing practice during menstruation by using peer group discussion which supposedly mediated by 387

female school teachers. 388

Parents are advised to: 389

Educate their daughters about the process, good personal hygiene, use of proper pads, and its proper 390

disposal. 391

Support their children with sanitary materials for menstrual hygiene. 392

Acknowledgment 393

It gives me pleasure to express my heartfelt gratitude to Addis Ababa University, School of Public Health 394

librarians for providing me the necessary references. I would like to thank to my advisor Worku Tefera 395

for his unrestricted guidance, envisioning and supporting from the period of instigation to this project. 396

I am also grateful to thank Addis Ababa education bureau, sub city education offices, school staffs, my 397

office staffs for their cooperation and assistance in giving important information. 398

I am pleased to extend my thanks to my brother, Mehary Biruk, for his devotion to support me through 399

the academic years. 400

I would also like to thank all the participants of the study for their patience and collaboration during 401

data collection. 402

I am exclusively thankful to my friends Ashagre Sisay, Ermias Woldie, Tasew Denbi, Nardos Tadesse and 403

Sintayehu Tadesse for their vital contribution for success of this work. 404

405

406

407

408

409

410

411

412




44

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